Sciatica, or nerve pain down the leg, is common with lumbar disc herniations. There is a body of thought that these all improve with time and rehabilitation. The result is that many clinicians suggest that patients ‘wait it out’. However, this is not necessarily the best course of action in all cases. A number of studies have shown that surgery gives better outcomes in certain circumstances. The first study, published in 2021, showed that patients who had sciatica for four months or more had significantly less leg pain after microdiscectomy surgery compared with nonoperative treatment, at the six month mark. Another study, again from 2021, found that early surgery (within one month) was beneficial in patients with nerve damage in the form of a foot drop with regard to the rate and degree of neurological recovery. Where the evidence is less clear is the effects of early surgery where there is no sign of nerve damage. Studies are conflicting and difficult to interpret, as many patients who were randomised to the nonsurgery group ended up having surgery because of intractable pain. Common findings were more rapid pain relief with surgery but no clear difference in outcome after 12 months.
It seems that early surgery is the best course of action for patients with significant nerve damage (most commonly foot drop) and surgery gives better outcomes if sciatica has persisted for more than four months. In cases without nerve damage, surgery is likely to lead to more rapid pain relief, but waiting for three to four months for improvement is also a safe and reasonable option.
Bailey CS, Glennie A, Rasoulinejad P, et al. Early Versus Delayed Microdiscectomy for Chronic Sciatica Lasting 4–12 Months Secondary to Lumbar Disc Herniation: A Secondary Analysis of a Randomized Controlled Trial. Global Spine Journal. November 2021.
Song, Nam, D. C., Moon, D.-K., Lee, D.-Y., Lee, E.-C., & Kim, D.-H. (2021). Surgical decompression timing for patients with foot drop from lumbar degenerative diseases: a meta-analysis. European Spine Journal.
Peul, Hout, W. B. van den, Brand, R., Thomeer, R. T. W. M., & Koes, B. W. (2008). Prolonged conservative care versus early surgery in patients with sciatica caused by lumbar disc herniation: two year results of a randomised controlled trial. BMJ, 336(7657), 1355–1358.